Vladimír Beneš Jr is professor and chair at the First Medical School, Charles University, Postgraduate School of Medicine, Central Military Hospital in the Czech Republic. He speaks to NeuroNews about how he grew up around neurosurgery and pursued the profession himself. He describes his work with the Czech Government, his time as a colonel in the army and his passion outside of medicine—entomology.
What drew you to medicine and neurosurgery?
My father, now 93, was a neurosurgeon and we lived some 100 metres from my father’s department (the one I am at now). My mother worked in the same hospital as the pharmacist. My best childhood friend is also the son of a neurosurgeon. Almost all our childhood games took place in the hospital gardens (some employees had little gardens there where they grew fruit and vegetables) parks and even inside the buildings. The hospital has a large gym, another place where I have spent a lot of time. At home my parents talked mostly about the hospital and neurosurgery. My father often worked at home and—unless he had some sports engagement—he was either reading scientific journals or typing on an antique typewriter. All this seemed perfectly normal and reasonable to me. In short, I grew up in a hospital and neurosurgical milieu. My parents never told me what they would like me to study and what should I do with my life but I have never considered other option but neurosurgery. Actually, it was exactly the same with my son. We never have told him what we would like him to do and he never considered any other options either. He now is a fully trained neurosurgeon with a PhD.
Who were your mentors and what wisdom did they impart to you?
Obviously and most importantly is my father. Although we have only met in the operating room two or three times, he passed on to me his philosophy, optimism, honesty and love for neurosurgery. However, he only started taking me seriously after I joined him at tennis doubles and on a football team when I was 17 or 18 and later on when I finished medical school and started my residency.
My second mentor was professor Mraček in Pilsen. I was with him for three years as a medical student and I have spent most of my time with him. At the time I was frequently his only staff, resident and nurse. Professor Mraček was like a machine—three times a week in the operating room, three surgeries a day, one day of outpatient clinic and one day of neuroradiology. At that time in our country the neurosurgeons did angiographies, pneumoencepalographies, and perimyelographies themselves. He taught me the importance of clinical findings and how to perform neurological examination, he taught me systematics and how to do the scientific work and all the technicalities of publications. I was taught the system, precision, and the value of facts.
My third mentor was my first boss when I was a resident, Dr Malý. He was an excellent neurosurgeon with complete lack of systematics and organisation, with hundreds of wild ideas; he had an erratic renaissance personality with hints of genius. From my point of view, one of his best features was that he did not need to operate much. However, he loved long and sometimes all night discussions. He taught me creativity, the value of unorthodox ideas and the importance of individuality.
The last of my mentors was professor Spetzler. I spent a year in Barrow Neurological Institute (USA) and I saw that an excellent neurosurgeon must have all of the above, but also an ability to sell it in a good way. I learnt that a good neurosurgeon must be a complex personality with abilities in many other fields—not only a surgeon with golden hands.
What lessons did you learn from your time in the army?
Coming to the army hospital and becoming a soldier at the age of 44 was a strange experience. Surprisingly, in many respects the freedom and management attitudes were much easier and more flexible than in the civil sector. On the other hand, we have rules which have to be obeyed, there are mechanisms which do not change, there is a clear hierarchy and a chain of commands in military speak. From this point of view, it was rather easy for the whole hospital to win the American JCI accreditation and for the neurosurgical residency programme UEMS/JRAAC accreditation. However, for me personally, my army career gave me one great pleasure and honour—at the time of my soldiering we joined NATO and that has been for me the definitive end of communism and definite exit from the Russian zone. I always have been proud to be a member of the Czech Army, and actually, as a retired colonel, I still am proud.
You were the chairman of the Committee for Surgical Disciplines, Scientific Board of the Ministry of Health of the Czech Republic—what did this role entail?
That was mostly about the grant agency of the Czech Ministry of Health. I evaluated the grant applications, scored the final reports, awarded grants and followed their progress. I still am a member of the committee in the neuroscience section and still, after 20 years, enjoy the work. I am able to help good projects and I enjoy seeing some excellent results. The reward is very important to me, I get a good overall orientation in many medical fields, I get to know good physicians and scientists and I am not restricted to the narrow field of neurosurgery. Without cliché, I believe I am doing some valuable work.
As president of the EANS board of officers, what can our readers expect from the meeting this year?
The EANS congresses are organised in four year intervals and they are always a highlight EANS activities. We always have a motto, this year it is “present limits of neurosurgery” and we always cover the whole discipline. Plenaries are given by the most outstanding personalities and only the best free papers are selected. Non-neurosurgeons would get, in five days of the congress, the update of entire neurosurgery with a glimpse into the future. The most prominent fields are oncology, skull base surgery, vascular neurosurgery, functional and spinal neurosurgery and neurotraumatology. A lot of attention is given to multimodality treatment—endovascular neuroradiology and radiosurgery amongst others. Most of neurosurgeons are open minded and tolerant individuals with strong opinions, thus the lectures, round table discussions, video presentations, and many other formats will be interesting to anyone. The Prague congress will be a truly worldwide event. We have invited our sister societies—the American Congress of Neurological Surgeons, Central and South American FLANC and Asian-Australian AASNS to join us.
You have been involved in many large trials such as CRASH, STICH, ACST, ISAT, and ARC; how do these data from these trials translate into practice?
Of those I was involved in ISAT probably had the most important influence on our daily practice. Before the trial, most aneurysms were clipped, now nearly 70% of them are treated endovascularly. Our overall results did not change much, subarachnoid haemorrhage has a given morbidity/mortality rate despite treatment modality. We are, however, treating more patients. It is not only the fact that some aneurysms are treatable by endovascular means only but more importantly, we treat aneurysms in older patients and in patients in a more severe condition. The other trial was STICH. Its results show that in surgery in patients with haematoma closer to the surface (10mm) is extremely helpful.
What are your current areas of research focused on?
I am mostly involved in two areas—vascular and oncology. In vascular we have been studying the correlation of various diagnostic techniques and actual carotid stenosis from removed plaque. All available techniques are underestimating the stenosis, thus in my mind the carotid endarterectomy indications are questionable, not as clear as is stated by the American Heart Association. The other major area is neuropsychological outcome after aneurysm treatment. In more than 500 neuropsychological studies we have proven that we actually do not harm our patients as much as we thought. More importantly, we have not seen any difference between patients treated surgically and endovascularly. We now have shifted our attention towards the arteriovenous malformation patients, post-ARUBA, we need some new data. The next large area covered by several grants is neuro-oncology. Being the proud owners of 3T intraoperative MR we are involved in intraoperative imaging field as well. Several projects and publications are obviously centred on spine surgery, too.
What innovations have changed neurosurgery in the last 10 years?
In the past 10 years we have taken many smaller steps like ALA techniques in gliomas, indocyanine intraoperative angiography and spine stabilisation devices. However, CT and MR changed neurosurgery fundamentally. I see the most important change in neurosurgeons psychology. In the 1990s the skull has been the fast developing area with surgeries being the pinnacle of what can surgically be done on a human being. There were no longer any inaccessible locations in the brain or spinal cord anymore. However, in 2010 we are much more reasonable and careful. The immense potential of alternative modalities is appreciated and routine approaches are preferred. The safety of surgery is the most important factor in decision-making now.
How do you see the field of neurosurgery developing in the future?
I am convinced neurosurgery is past its zenith from a surgical perspective. That was the 1990s. Spine surgery will remain and develop technically for another several years (until biological treatment with cultured cartilage and bone takes over). Spine will become somewhat separate and independent field anyway. In general, we shall operate less but safely, there will not be heroic surgeries with neurosurgical giants. We shall be much more function oriented with perfect imaging techniques. Surgery will be one of the treatment modalities, still the most effective, precise and fast but still somewhat risky and emotionally not preferred by patients. Modulating techniques will be fast developing for not only pain and Parkinson’s. Gliomas will disappear as non-surgical disease. Vascular diseases will mostly be treated endovascularly. On the other hand, thanks to permanent shortening of the working time we shall see many inexperienced and under educated and trained neurosurgeons (however they will be well rested). We shall see fewer top institutions, but those that are will really be the top. Mentally, neurosurgery in future will be more challenging, exciting and rewarding thanks to its reconstructive potential.
What are your interests outside of medicine?
Theatre: Prague has some 100 theatres, most of them of high quality. Literature—our house is full of books, they spill everywhere and are hardly opened because both my wife and I have small e-readers. History: I am interested in the Egyptian and Roman empires and World War II. I also like sports such as skiing and a favourite—tennis. I am an amateurish enthusiast and will spend any free time at the courts which are three minutes from our house.
The hobby that is most deeply embedded for me is entomology. I have collected beetles since my childhood and for the past 25 years I disappear each year for a collecting trip. I have been to China, Mexico, Brazil, Panama, Australia and other places many times. It is the atavistic hunt that I love. Back home, when the beetles are determined and mounted, I get the feeling of adventure from the trip from just seeing any of the 15,000 specimen I have at home. Professional entomologists have described some 15 new species which I have collected so far in my name. I also have co-authored one new description.
My wife and I now have twin granddaughters, four years old—maybe they will be the fourth generation in neurosurgery? Who knows.
Chief of Neurosurgery, Central Military Hospital,
Chairman department of Neurosurgery, First Medical Faculty, Charles University, Prague,
Head of Neurosurgery, Postgraduate Medical Institute, Prague
(all three posts are based in the Central Military Hospital, operated jointly by the Ministry of Defence, Ministry of Education and Ministry of Health)
1988 Deputy head, department of Neurosurgery, Masaryk Hospital, Ústí nad Labem
1996–1997 Head, department of Neurosurgery, Masaryk Hospital, Ústí nad Labem
1994–1997 Head, department of Neurosurgery, University Hospital, Motol, Prague
1997 Lt. Colonel, Czech Army
2003 Full Colonel in 2003
2013 Retired from Army
1973–1978 Medical school Charles University, Prague
1978–1987 Residency, general surgery and neurosurgery, Masaryk Hospital, Ústí nad Labem
1996 Editorial board of Bolest (Pain) and Czech and Slovak Neurology and Neurosurgery
1995 Co-editor Acta Neurochirurgica (European Affairs)
2003–2007 Editorial board, Advances and Technical Standards in Neurosurgery,
2007–present Advisory board, Neurochirurgie and Central European Journal Neurosurgery
2010–present Advisory board, Neurosurgery
2009–present Advisory board, World Neurosurgery
2011–present Editorial board, Acta Neurochirurgica
1998–present Examination Committee in Neurosurgery, committee chairman